Autumn 2009: Features
Health of a Nation
How has U.S. health care become a political lightning rod, an economic sinkhole, the most divisive national issue since Vietnam, and President Obama’s biggest challenge?
By Andy Miller
The applause, boos, and occasional shouts had the intensity of a championship sports event. This gymnasium crowd, though, was reacting not to athletic feats, but to phrases that seemed geared more to a grad school seminar:
Public option. Rationing. Wallet biopsy.
The audience in the Georgia Perimeter College gym voiced their sentiments on health care reform at an August town hall meeting held by Congressman Hank Johnson, a Democrat. In fact, the gym, where about a thousand people watched a closed-circuit TV feed, wasn’t even the principal venue. The first five hundred found seats in the college auditorium, and there were hundreds more outside, holding signs against “ObamaCare” or in favor of health insurance reform.
Extra security officers stood ready; even the parking lot had protesters. The tone of the Johnson town hall in Clarkston may have lacked the hostile confrontations of other congressional reform gatherings, but nonetheless, passions flowed.
A woman at the main gathering talked of her children with epilepsy and diabetes and her astronomic monthly premiums for health insurance. A small business owner complained of a 25 percent increase in the cost of covering her workers. One physician on the panel argued for tort reform and against “government control” of health care. Another doctor backed the Democrats’ initiative, saying, “the status quo is unacceptable.”
This summer, health care reform captured the attention of a nation, and even its more theoretical provisions blasted into people’s consciousness. The public followed the debate on television, talk radio, and the Internet with a fervor befitting a presidential campaign. Finally, everyone was noticing “the pink elephant in the room with the lampshade on,” as town hall meeting panelist Michael Young, CEO of Grady Health System, put it.
How had this elephant of an issue clambered to the top of the country’s domestic agenda, giving rise to possibly the most significant legislative package in years? And what factors were present this year that gave health care reform a fighting chance of becoming law?
Perhaps a critical mass had been reached.
President Obama had pushed a broad overhaul of the $2 trillion-a-year system during his campaign. The Democrats held strong majorities in both houses of Congress. A recession was still roiling the country with massive job losses. And even ferocious critics of the Democrats’ reform initiatives perceived the myriad problems that beset America’s health care system.
The United States spends much more per capita on health care than any other country, yet, according to the World Health Organization, is not nearly as healthy as other countries, ranking thirty-seventh in overall health system performance and seventy-second on level of health. Then there’s the matter of 47 million-plus without health insurance and many millions more with threadbare coverage that leaves them vulnerable to huge out-of-pocket expenses.
“There are some things that are very wonderful about the system and some things that don’t make sense,” says Michael M.E. Johns, Emory’s chancellor.
Many ordinary Americans feel the problems personally, whether it’s the rise in their premiums, copays, and deductibles every year, or, on the flip side, their employer trying to crunch the math to preserve coverage for employees. Health care costs have risen much faster than the general inflation rate, with premiums doubling in the past decade.
Several factors drive these increases. “A lot of it is advances in technology—new approaches, new treatments,” Johns says. The technology can improve quality of life for patients, he notes, but the price of innovation is steep.
Also contributing to the costs, he adds, is defensive medicine, in which doctors administer test after test to protect themselves from litigation. “The biggest lawsuit for primary care physicians is failure to diagnose,” says Johns, who led the health sciences at Emory from 1996 to 2007.
Then there are the billions wasted on insurance transaction costs. “The hassle factor for physicians is enormous,” Johns says. “It’s a lot more paperwork, especially for primary care doctors.”
Another cost driver, notes Ani Satz, an associate professor with a joint appointment in Emory’s schools of law and public health, is the impact of medical errors. She cites the landmark Institute of Medicine report in 1999 that made the famous estimate of forty-four thousand to ninety-eight thousand deaths each year resulting from medical errors. In addition, many patients with job-based insurance, Satz adds, are insulated from the real costs of care, leading to unnecessary visits to physicians. “Patients are unsophisticated consumers of health care,” she says.
How did this system—one that nobody could ever dream up from scratch—evolve?
The current tangle of government coverage, employer-based insurance, individual coverage, and no insurance at all came about as a historic accident.
“In World War II, there were wage and price controls,” says Paul Rubin, a professor in Emory’s Department of Economics and a professor of law and economics at the School of Law. “Firms wanted ways to attract workers. Government decided they could give workers health insurance, and it was tax free. At the time, health insurance was cheap. Medicine couldn’t do so much then.”
Major government insurance expansions occurred in the 1960s—though not without opposition—when President Lyndon Johnson pushed Medicare and Medicaid through Congress. “Medicare was passed, a wonderful thing for the elderly,” Johns says. “The AMA [American Medical Association] was violently opposed to it and thought it was going to be the end of the world.”
Meanwhile, countries in Europe had created their own systems that relied on government-run medical services. “Each country developed in its own way, and developed it in a prior era, when countries had more control over the economy,” says Richard Saltman, professor in the Department of Health Policy and Management at the Rollins School of Public Health. Now, though, European governments are steering spending more directly and requiring medical providers to improve quality of care—generally tightening the central authority over their health systems.
But despite criticism by American conservatives, their systems remain popular, says Saltman, an expert on European health care. In Britain, “it’s part of their identity,” he says. “They think their system has problems, but they’ll defend it.”
Patrick Allitt, a professor of history at Emory, is a case in point. Born and raised in England, Allitt believes the National Health Service there “is an excellent system and is universally liked.”
While he acknowledges the British system is “less good with nonemergency procedures,” Allitt says supplemental health insurance is available, and “there is no tradition of malpractice lawsuits.”
Still, the U.S., with its different culture, geography, and institutions, continued to go its own way on health care during the 1970s and 1980s. “Americans have a preference for individualism and market solutions,” says psychology and psychiatry professor Drew Westen. He also points to the influence of political contributions from the health industry to members of Congress as a reason why the system has remained largely intact.
Though Harry Truman, Richard Nixon, and Jimmy Carter sought to change the health care system, the most promising attempt occurred when Bill Clinton took office in 1993, empowered by a broad mandate to enact reform. Clinton turned the initiative over to his wife, Hillary, who set up work groups, meeting in secret, to devise the plan.
“The Clinton administration took a long time to pull the proposal together and did not involve the leadership of Congress very much,” says Randall Strahan, professor of political science. “The bill turned out to be extremely complicated. The political wisdom in Washington shifted from something that was inevitable to something that may not succeed.”
The Clintons lost momentum. Later in 1993, the very effective “Harry and Louise” ads, paid for by the insurance industry and criticizing reform, sealed their fate: the Clinton plan died without a vote. A few years afterward, though, the Clinton White House helped pass the 1997 Children’s Health Insurance Program, a successful initiative that has insured millions of children of lower-income parents.
Even so, in the decade since the Clinton era, the cost of health insurance premiums has continued its inexorable rise—as has the number of uninsured. Arthur Kellermann, associate dean for public policy at Emory’s School of Medicine and an emergency department physician at Grady, estimates the uninsured at 50 million. “It is dramatically destabilizing the health care system,” he says.
Yet the medical world, despite the influx of managed care, has maintained the traditional fee-for-service model that pays providers for each procedure. “Doctors and hospitals and vendors were able to leverage and dramatically grow their revenues,” Kellermann says. “They’re paid to do more rather than better. As [health care] has become more expensive, more people were priced out of the market.”
Businesses, dealing with dizzying annual increases in their health care costs, have reduced coverage and pushed more costs onto workers, adds Chip Frame, adjunct associate professor of marketing at Goizueta Business School. “Obviously, the recession has brought everything into a clear focus,” says Frame, who also is executive director of the Emory Center for Healthcare Leadership. “Businesses are more willing to look at avenues to moderate the costs.”
The past year has seen the merging of the cost crisis surrounding health care and the system’s inequities with a new political alignment supporting reform. “It is a window of opportunity for a large-scale, nonincremental change in public policy,” Strahan says. “Those don’t come along that often. It’s relatively rare when the stars are lined up.”
But changing a $2 trillion-a-year system isn’t easy work—and it’s a system in which just about everyone has a personal and emotional stake.
“It’s easier for people to perceive how [change] is going to hurt them versus perceiving how it’s going to help them,” says political science professor Alan Abramowitz. “You have some very entrenched interests: Drug companies, insurance companies, doctors, hospitals all have a big stake in what happens. We spend a huge amount and arguably there’s a lot of waste. But what looks like waste to some is profit to others.”
The recession also has made many Americans feel that the loss of private health insurance is just a pink slip away. “People are angry about what’s happened to their personal financial security over the past year,” says Westen. “We’ve all seen the value of assets drop in half, people lose their homes. Bankers taking their homes are giving themselves big bonuses, courtesy of taxpayers. The average voter should be enraged.”
The downturn appears to cut both ways on health care reform. Rubin believes the recession makes it less likely to pass an expensive plan. “People are tired of the government spending a lot of money,” he says.
On the other hand, Obama’s argument is that the recession is a reason for doing health reform now. Health care, in fact, has emerged as a defining moment in his early presidency, and it’s tough to say how it will position him. Obama based his candidacy on a message of change, yet the U.S. health care system has proved an immovable object for decades. And he has chosen not safe, incremental reforms, but a sweeping overhaul that carries great political risks.
He also took the opposite legislative approach than the Clintons used sixteen years before. “The White House gave stakeholders a lot of leeway in forming the health care plan,” notes Andra Gillespie, assistant professor of political science. “Obama would have been better served outlining what he wanted Congress to do.”
Westen is also critical of how the president has failed to tell the story of health care reform and why it’s needed. That narrative, he says, would include “why more and more Americans are seeing their claims denied, their premiums go up, or [being] unable to obtain insurance because of a preexisting condition. If you’re not willing to tell the stories, if you’re fundamentally afraid of conflict, you cannot win this debate.”
By late summer, opponents of the coalescing overhaul plans had largely taken control of the tone and direction of the debate. Their central theme—government takeover of health care—was ultimately symbolized by the Democrats’ proposal for a public option, run like Medicare, to compete with private health insurers. The rhetoric ramped up, along with some distortions such as “death panels,” which weren’t a part of reform legislation but took on a life of their own.
If nothing else, the public’s attention this summer was riveted on health care to an unprecedented degree. Ordinary citizens filled town hall meetings, venting their anger variously on insurance companies or government meddlers. That the theoretical notion of a ‘‘public option” could inspire signs and chants speaks to a stunningly broad emotional connection.
“Health care, probably more than anything else, is susceptible to the most personal vignettes,” Frame says. “It’s really almost visceral. It really strikes at the core of what we are as human beings.”
And what if nothing substantial is passed on health reform? What if all this energy dissipates with legislation dying in Congress?
Kellermann, who treats uninsured patients at Grady every week, sees an already fragile system devolving further: more people without insurance, and more people underinsured. Doctors shunning primary care and the tough medical cases. Hospitals closing. And an avalanche of American companies dropping health insurance or stripping it to bare-bones benefits, deciding they’re not going to carry the financial burden anymore for their employees.
“The status quo,” Kellermann says, “should be everyone’s last choice.”
Andy Miller is a former health care reporter for the Atlanta Journal-Constitution and a freelance writer living in Atlanta.